Acupuncture Case Studies

Words: 481
Pages: 2

According to MTUS, acupuncture is used as an option when pain medication is reduced or not tolerated, and it may be used as an adjunct to physical rehabilitation to hasten functional recovery. Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase the range of motion, decrease the side effect of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.

I have carefully reviewed the documentation presented. The patient complained of pain in the low back and right hip. Examination revealed right hip tenderness, lumbar spine tenderness with a decreased range of motion and spasm. A request was made for acupuncture therapy. However, there was no documentation that the medications prescribed were reduced or not tolerated. Furthermore, there
…show more content…
The patient was climbing down a unit-haul truck when she suddenly sustained a right hip pain. The pain started to shoot down to her entire right lower limb. She also developed numbness in the right leg.

The patient was diagnosed with a right side sciatica and bursitis of the right hip.

Treatments rendered to date included medications, activity modification, steroid injection, physical therapy (PT), and chiropractic care.

The right hip x-ray dated 08/22/16 revealed no significant interval change, no acute fracture, no significant joint disease, and no significant soft tissue abnormality identified. The alignment was normal. There was a mild multilevel degenerative disk disease with marginal osteophytosis present in the dorsal spine.

An MRI of the lumbar spine dated 8/2016 revealed facet disease and disc bulge on the right.

Medical records reviewed included Primary Treating Physician’s Progress Report (PR-2) dated 05/23/17, Request for Authorization (DWC Form RFA) dated 05/24/17, and Mitchell, UR Notice of Prospective Authorization Decision dated 08/23/16 and